CEO and Physician For Illinois Company Who Billed Medicare For In-Home Patient Visits Charged With Medicare Fraud And Making False Statements Relating To Health Care Benefits

A recent case in Illinois shows that the government is investigating home health billing including in-home physician visits and home health agency and other related billings to Medicare. This case shows how a mobile doctor company and its financial ties and referrals have been investigated.

On August 27, 2013, the CEO of Chicago-based Mobile Doctors, Dike Ajiri, which manages physicians who make house calls in six states, and Dr. Banio Koroma (one of its physicians in Chicago) were arrested on federal health care fraud charges. At the same time, federal agents executed search warrants at Mobile Doctors’ offices in Chicago, Detroit, and Indianapolis, as well as warrants to seize up to $2.568 million in alleged fraudulent proceeds from various bank accounts. The federal complaint was filed in the Northern District of Illinois. The public is reminded that a complaint is not evidence of guilt. The defendants are presumed innocent and are entitled to a fair trial at which the government has the burden of proving guilt beyond a reasonable doubt. 

The criminal complaint allege a scheme to fraudulently increase (also known as “upcoding”) Medicare bills for in-home patient visits that Mobile Doctors falsely claimed were more complicated and longer than they actually were. 
The charges also allege that Mobile Doctors’ physicians falsely certified that patients were confined to their homes, enabling home health care agencies to claim fees for additional services for patients who were not actually qualified to receive them. There are also allegations of billing for medically unnecessary tests and for services not performed by a physician. 

Mobile Doctors in Chicago arranged patient home visits and contracted with doctors who perform the visits. The physicians assigned their rights to bill and collect payment to Mobile Doctors in return for being paid directly by the company. Mobile Doctors’ website claims that its associated physicians have made more than 500,000 house calls since its inception. In addition to Chicago, the company has branches in Detroit and Flint, Michigan; San Antonio and Austin, Texas; Indianapolis; Kansas City; Phoenix; and St. Louis. 

CEO Ajiri was charged with health care fraud, and Dr. Koroma was charged with making false statements relating to health care benefits. According to a 75-page affidavit in support of the arrest, search, and seizure warrants -- which is an outline of the government's case -- agents interviewed several current and more than 25 former employees of Mobile Doctors, including some who reported allegedly fraudulent billing practices to Medicare before they were contacted by agents. 

Investigators also reviewed e-mails and documents, claims data and patient files and have conducted interviews with patients of Mobile Doctors and their primary care physicians, whose statements allegedly contradict Mobile Doctors’ billing and patient records. 

Ordering Diagnostic Tests. Mobile Doctors physicians do not perform tests such as echocardiograms but do order such tests, which are done on Mobile Doctors’ patients by employees of In Home Diagnostics, doing business as Ultrasound2You. According to Medicare records, Mr. Ajiri is a minority partner in In Home Diagnostics, which is located in the same building as Mobile Doctors, and Mobile Doctors bills the echocardiograms so that they appear to have been done by Mobile Doctors’ physicians. Any referrals will be closely scrutinized for medical necessity and whether there is any violation of the anti-kickback/referral statutes.

Financials. The financials were key to the government's investigation as well. The complaint affidavit states that Mr. Ajiri signed a personal financial statement on December 31, 2012, stating that he received $1.5 million in annual partnership income from a corporate entity, Mobile Doctors LLC, which has a complex ownership structure involving Mr. Ajiri and, over time, one or both of his parents. Between 2008 and January 2013, bank records show that approximately $4.365 million was transferred from Mobile Doctors to an account in the name of Mr. Ajiri and his wife. 

Interviews With Former And Current Physicians, Employees and Patients Regarding Upcoding. The affidavit alleges there was upcoding and that according to interviews with former and current Mobile Doctors physicians, branch managers, clinical coordinators, employees, and patients, a typical visit that a Mobile Doctors physician has with an established patient lasts 10 to 30 minutes and is routine in nature. In contrast to those interviews, claims data shows that from 2006 through February 2013, approximately 99 percent of all established-patient visits by Mobile Doctors physicians were billed to Medicare using either of the two highest codes indicating the visits involved medical decision-making of moderate to high complexity, detailed or comprehensive interval histories or medical examinations, and/or visits that typically last at least 40 minutes. In 2009 in Chicago, the local Medicare fee for a visit using the second-highest home visit code was approximately $122.82, while the fee for the highest code was approximately $171.25. 

Claims Data Analysis For Billing Codes. The agents conducted a review of claims data for Railroad Retirement Board patients, and allege that every single established-patient visit Mobile Doctors billed to Medicare between January 2007 and June 2008 used the highest fee code. It is also alleged that between January 2007 and November 2012, approximately 93 percent of such visits were billed using the highest fee code. 

The former manager of Mobile Doctors’ Chicago branch until she was terminated in 2008 told agents that Mr. Ajiri told her that the second-highest fee code was the default code for a patient visit so that it would be worth the gas and time spent. The manager said Mr. Ajiri told physicians, “I don’t pay for ones or twos,” referring to the two lower of the four applicable fee codes. At the end of one day, she said she saw Mr. Ajiri in his office “automatically” altering the billing codes and marking visits at the highest fee level on patient records submitted by physicians and assistants who accompanied them on home visits. 

Interview With Physician. A physician told agents that in late 2007, Mr. Ajiri did not respond to his concerns about Mobile Doctors’ billing practices and instead told the doctor that he could earn more money if he would order more tests such as electrocardiograms, according to the affidavit. The complaint alleges that the vast majority of payments made on established-patient visit claims using the highest fee code were the result of fraudulent upcoding. From 2006 through 2012, Mobile Doctors received approximately $21.4 million in payments on claims using the second-highest code and approximately $12.6 million in Medicare payments on claims using the highest fee code. 

Falsely Certifying Patients as Confined to Their Homes. The charges further allege that Mobile Doctors physicians, including Dr. Koroma, falsely certified patients as confined to their homes and requiring home health services when they were not home-bound and did not require such care. By referring patients to home health agencies that did not warrant Medicare payments, Mobile Doctors received more referrals from those agencies for services provided by its physicians. According to Medicare data, from August 2010 through July 2013, more than 200 home health agencies submitted Medicare claims for services allegedly rendered to patients for whom Dr. Koroma was identified as the referring physician. These home health agencies have been paid more than $10 million for services listing Dr. Koroma as the referring physician. 

Between January 2006 and March 2013, Mobile Doctors physicians have certified or recertified for 60-day periods approximately 15,598 patients as confined to their homes and requiring home health services a total of approximately 83,133 times, many of which were allegedly false. Approximately 6,057 of these certifications were attributed since August 2007 to Dr. Koroma, with Mobile Doctors billing Medicare for approximately 17,439 patient visits he made during that time, more than any other Mobile Doctors physician. 

The health care fraud count against Mr. Ajiri carries a maximum penalty of 10 years in prison and a $250,000 fine and restitution is mandatory. The false statements count against Dr. Koroma carries a maximum of five years in prison and a $250,000 fine. If convicted, the court must impose a reasonable sentence under federal statutes and the advisory United States Sentencing Guidelines.

Posted by Tracy Green, Attorney at Law, Green and Associates
You can reach Ms. Green at 213-233-2260 or tgreen@greenassoc.com

Nurse Practitioner Bill Suffers A Setback in California

Nurse practitioners in California suffered a setback in their ability to practice independently of physicians if they are part of a medical team such a clinic or group practice. On August 30, 2013, Senate Bill 491 (Hernandez), which would remove patient barriers to health care services by permitting nurse practitioners in California to practice to the full extent of their training and expertise was held in the Assembly Appropriations Committee. The bill was not voted upon and will not move during this legislative session. The California Medical Association vigorously opposed this bill. The Los Angeles Times' article on SB 491 provides more background on the lobbying and issues present. 

Under current law, NPs have a difficult time providing services at the point of care because of requirements for physician approval to initiate or continue care that patients need.  This bill would increase autonomy for NPs to be able to provide this care. The California Association for Nurse Practitioners viewed SB 491 as especially important with the coming implementation of the Affordable Care Act, and the expected influx of up to 7 million new patients into the health care delivery system in California. The Los Angeles Times wrote an article indicating that this is a step in the right direction.

The argument in favor of the bill was that NPs would not be performing outside of their level of education and training, but would be utilized to their full practice potential without the archaic and restrictive barriers that prevent patients from receiving high quality, effective care. In addition, 18 other states and the District of Columbia permit autonomous delivery of primary care services by nurse practitioners.  

We can expect to see a revised bill presented next year regarding expanding the use of nurse practitioners in clinic and group practice settings.

Posted by Tracy Green, Green and Associates, Attorneys at Law

You can reach Ms. Green at tgreen@greenassoc.com or 213-233-2260

San Jose Psychiatrist Arrested For and Charged With Prescribing Controlled Substances Without A Legitimate Purpose and Prescribing to an Addict

The Medical Board of California has a Prescription Drug Strike Force. Recently, they conducted an investigation into a San Jose physician after receiving a complaint alleging that this doctor, Duke D. Fisher, a psychiatrist, would prescribe any medication the patient wanted in exchange for cash. The Board conducted multiple undercover operations at his office.

In our experience, these undercover operations are usually videotaped. If the undercover operation is not successful for prescription sought (such as Oxycontin), they will send undercover investigators back in and request other controlled substance prescriptions (such as Vicodin, Adderall, Xanax, etc.).

Based on the results of the undercover operation, the investigators determined that they had probable cause to believe that Dr. Fisher prescribed controlled substances without a legitimate medical purpose and prescribed controlled substances to an undercover customer who admitted to using heroin and methamphetamines.

On August 29, 2013, an arrest warrant was issued by the Santa Clara District Attorney's Office, bail was set at $64,000, and Dr. Fisher was charged with the following counts:
(1) prescribing without a legitimate medical purpose in violation of California Health and Safety Code Section 11153;
(2) prescribing to an addict  in violation of California Health and Safety Code Section 11156; and
(3) prescribing to an addict in violation of California Business and Professions Code Section 725.

Attorney Commentary

Physicians who prescribe controlled substances need to assume that everything is being recorded and that their records will be reviewed to determine if there is "legitimate medical purpose." If your personality is to trust patients -- and for physicians trained years ago who were not in the habit of cross-examining patients -- it must be remembered that when "red flags" appear, such as disclosing prior illegal drug use, conservative action must be taken.

Physicians remember that you cannot help any patients if you put your license in jeopardy. You need to set boundaries and remember that the only way in which you will not be accused of overprescribing or distributing controlled substances is if your records prove there is legitimate medical purpose and that you are not prescribing to an addict. For patients who have medical issues that require scheduled substances, they have to understand that they need to agree to the terms of your medication management agreement or they cannot be prescribed scheduled substances.

At a minimum, physicians who prescribe controlled substances need to do the following:

(1) register for the CURES database and run reports on all new patients and regularly on existing patients (some psychiatrists who treat patients with medications are not as careful on these points as are pain management physicians);
(2) remember that the CURES system is not perfect and do not rely solely on it;
(3) record all drugs dispensed and prescribed in the patient chart and keep copies of the prescriptions in the patient's chart;
(4) conduct the appropriate physical exam and obtain records from prior physicians and speak to those physicians;
(5) have pain management or medication agreements with patients that are followed and document when the agreement is breached;
(6) have a system in place that addresses the patients' medical issues and refer to specialists as needed; and
(7) remember that spending a weekend to address your practice and compliance is well worth the effort.

Once your practice has been open for some time, it is critical to revisit policies and procedures once a year just to protect yourself and your practice.


Posted by Tracy Green
Green and Associates, Attorneys at Law
tgreen@greenassoc.com
213-233-2260